Sequence of the therapy
The sequence of therapeutic interventions for acute myocardial infarction (AMI) should follow the following sequence: A further distinction is made between interventions in the prehospitalization phase, i.e. the time before the patient arrives at the hospital, and the hospital phase, in which the patient is in hospital. Ideally, the general measures should be taken during the prehospitalization phase, i.e. before the patient arrives at the hospital.
- General measures (securing life)
- Reperfusion therapy (reopening of closed coronary vessels)
- Prophylaxis of coronary re-thrombosis
- Therapy of complications
Treatment after a heart attack
In the acute situation of a heart attack, vasodilating drugs (e.g. nitrospray) and oxygen are administered first. This improves the supply of oxygen to the heart muscle cells. Painkillers should also be given.
Afterwards, the narrowed area in the coronary arteries should be removed or widened. This is usually done with a stent or a bypass. Depending on the long-term consequences, different drugs are then administered.
Blood thinners are intended to prevent blood clots from forming in the event of cardiac rhythm disturbances. In addition, there are drugs that prevent these rhythm disturbances. The use of a pacemaker also helps.
If the heart is so damaged that it could possibly stop on its own, it is advisable to install a defibrillator. If a heart attack results in cardiac insufficiency, cardiac glycosides (digitalis) are usually prescribed. Diuretics (water tablets) are also helpful, as they relieve the load on the heart.
Depending on the disease underlying the infarction, this too can be treated. Antihypertensives make sense when blood pressure is too high. Statins bring the blood lipids back into balance.
Immediate therapyAcute therapy
If there is the slightest suspicion of a heart attack, immediate admission to the clinic with the emergency ambulance in medical care and subsequent hospitalization is necessary. The aim of immediate transport to the hospital is to initiate reperfusion therapy within 12 hours of the onset of the infarction so that the damage to the heart muscle caused by the infarction can be contained as far as possible. The faster the occluded coronary vessel is reopened and blood circulation is restored, the less heart muscle tissue dies and the fewer complications occur due to the heart attack.
The motto of acute therapy for a heart attack is therefore: “time is muscle”. Certain initial measures must be taken immediately. The affected person should be stored with a raised upper body and oxygen should be supplied via a nasal probe to supply the damaged heart with oxygen.
Consistent monitoring of the heart rate, heart rhythm, oxygen saturation and blood pressure via a monitor or an electrocardiogram (ECG) is necessary. Under certain circumstances, it may be necessary to deliver electrical impulses (defibrillation) to treat life-threatening cardiac arrhythmias or ventricular fibrillation. In most cases, a heart attack causes severe pain, which should also be alleviated by painkillers (analgesics) as acute therapy.
Opiates are usually given via the vein. In addition, sedatives, e.g. benzodiazepines (sedatives), are administered to reduce excitement (e.g. anxiety, agitation).
Nitrates (e.g. nitroglycerin) are given to relieve the heart and also have a beneficial effect on infarction pain. The early administration of beta-blockers (e.g. esmolol) can prevent cardiac arrhythmia and left heart failure (the most common complications after a heart attack). Beta-blockers also slow down the work of the heart (heart rate).
This leads to a reduction in the oxygen demand of the heart and thus the extent of the damage to the heart muscle caused by the heart attack is reduced. The immediate administration of acetylsalicylic acid (ASA), even if a heart attack is suspected, has shown ini studies to reduce the mortality rate by over 20 percent. However, not only acetylsalicylic acid is administered to prevent a new formation of a thrombus (blood clot), but also the drugs heparin and prasugrel or ticagrelor.The growth of an existing thrombus, which causes the patient’s symptoms, can be contained by the application of heparin.
It enhances the effect of the antithrombin III present in the blood, which inhibits blood clotting by promoting the dissolution (fibrinolysis) of a platelet aggregate. If blood pressure is very low in the case of a heart attack or if right heart attack is suspected, the administration of fluid via the vein is also part of acute therapy. In some cases, it is necessary to administer medication against nausea and vomiting (antiemetics) (e.g. metoclopramide).
Drug therapy to dissolve (lyse) the blood clot should also be started as early as possible in the event of an acute heart attack. Lysis therapy is all the less effective the longer ago the heart attack occurred. These lysis medications inhibit the body’s own blood clotting throughout the body and can thus lead to heavy bleeding (e.g. from a previously undetected stomach ulcer). For this reason, those affected must be closely monitored following lysis therapy.